Abandon the term “second victim”
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1233 (Published 27 March 2019) Cite this as: BMJ 2019;364:l1233
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Why are harmed patients expected to coin another term? It is not the responsibility of harmed patients to come up with one. But it is the responsibility of the medical profession to do no harm and not have a term which in any way furthers the mental distress of the true victims of medical errors.
Competing interests: No competing interests
The BMJ’s Editorial ‘Abandon the term “second victim” (BMJ 2019;364:l1233) seems to have misunderstood entirely the motives of Albert Wu and others since this term was introduced. It is no surprise that it has become widely used as it serves an important purpose. Firstly, in no measure does the acknowledgement that there is a second victim (eg. the doctor or the nurse involved in the clinical care) diminish the importance and seriousness of the injury (or complication) sustained by the patient.
Secondly, what it does allow is to develop an understanding that the medical practitioner is also subject to the consequences of an error whether it be systemic or individual much as a train driver suffers from post-traumatic stress syndrome when someone throws themselves to their death under a train. The benefit of seeing that there are two victims is that a dialogue can be generated to improve the lot of both parties both now and, more importantly, in the future.
Many medical errors or complications do not result from wilful neglect or oversight of the professional involved. Take an example in my field of colorectal surgery. The conventional treatment of cancer of the colon or rectum is to resect the tumour and if possible join up (or anastomose) the remaining bowel to give the patient a near normal quality of life and the best (and sometimes the only) chance of cure. But there is a known risk that 10% of these anastomoses fail and of those that leak a proportion will not survive.
Without exception every colorectal surgeon has had leaks and occasional deaths from this surgery for it is recognised that it happens in the best hands. The feelings that arise when this occurs are severe and often suicidal thoughts can follow. Certainly future performance is diminished if these feelings of the second victim are not recognised by others and addressed.
Although the authors of the editorial are right that the patients are the first and most important victims of medical errors, we all know of doctors who have killed themselves over these incidents. I contend, therefore, that the term second victim is useful and should still stand.
Peter McDonald MBBS MS FRCS
Consultant Surgeon, St. Mark’s Hospital, Harrow, Middx HA1 3UJ
Competing interests: No competing interests
Its is ironic this article is published in the same edition that leads with the news that Hadiza Bawa-Garba will be allowed to return to medical practice.
She was imprisoned, fined, lost her career, vilified in the lay press and racially abused on the internet.
That sounds like a "victim" to me.
Competing interests: No competing interests
Clarkson and colleagues called for abandoning the term “second victim” which was introduced by Albert Wu in 2000.(1,2)
Frist, they failed to provide an alternative. Pragmatically, how to label cases such as :
a) Hadiza Bawa-Garba in UK;(3)
b) Eric Delous, a 31 y chief fellow in anaesthesiology who committed suicide in 2010, one week after being suspended in emergency after a medical error at the univesity hospital of Montpellier.(4)
Second, Clarkson and colleagues wrongly claimed “Wu wanted to bring attention to the need to provide emotional support for doctors”.(1)
a) Clarkson and colleagues missed Wu’s aim may as it was in his conclusion: “patient safety”. “Patient safety and physician welfare will be well served …“(2)
b) Wu has concerns for all “nurses, pharmacists, and other members of the healthcare … vulnerable to its fallout.”(2) Nurses are not only at the front line for care but also are the most vulnerable during crisis, for such ones as for others.(5) An example, among too many, chosen because most recent and in my town: Angélique Beaupère, a nurse was suspended in emergency for a medical error at Pinel Psychiatric hospital and the case was only dismissed in April 2019 by the Court of Appeal after a decade of serial lawsuits.(6)
It is presumptuous but I will try to explain from the bottom, being a lay clinician, to the top, biomedical informatics which happily will replace healthcare professionals by with artificial intelligence to avoid errors. In brief, the theory: “errors” are not clear wrongdoing and “analyses should focus less on individuals and more on organisational factors” which is not the case yet (see above).(7) In brief, for the practice, those who accept to serve despite poor organisational factors are those involved in errors. Indeed “stupid presumptuous heros” could replace “second victim”. Doing nothing is the best method to avoid errors.
1 Clarkson MD, Haskell H, Hemmelgarn C, Skolnik PJ. Abandon the term "second victim". BMJ 2019;364:l1233.
2 Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ2000;320:726-7.
3 Ross N. Second letter to the GMC chair regarding Hadiza Bawa-Garba. BMJ 2018;360:k667.
4 http://www.lefigaro.fr/flash-actu/2010/04/06/97001-20100406FILWWW00670-c...
5 Braillon A, Bewley S.BMJ 2015;350:h1687Which whistleblower is more vulnerable: the Indian doctor or nurse?
6 https://www.francebleu.fr/infos/faits-divers-justice/amiens-la-relaxe-co...
7 Vincent C, Taylor-Adams S, Chapman EJ et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ 2000;320:777-81
Competing interests: No competing interests
We read carefully the article by M. D. Clarkson and colleagues (2), and we agree with some of its content, especially the need for a patient-centred medical culture.
We do not agree with the authors, however, when they ask us to stop calling healthcare professionals affected by medical harm “second victims”.
What does the term “victim” mean?
The word has a Latin origin, coming from the term “victus”, which means “defeated” or “beaten”.
When medical harm occurs, it means that the involved healthcare professionals have fought a battle and lost. By contrast, when the enemy (the main illness) is overcome, they won but suffered losses (side effects, complications).
Patients are victims, but not the only ones. They fight and lose. But they do not fight alone; they’re not the only losers.
There’s absolutely no appeal in the status of victim; rather, when medical harm occurs, physicians experience the failure and share the heavy burden of suffering felt by the patient.
That’s very far from the claim of no responsibility!
Every day, we fight a battle against an invisible enemy, hidden in the bodies of our patients. We ask them to join forces, and the new-born therapeutic alliance allows us to trust one another and hope that everything will go the right way. When things go wrong, it can be for unpreventable reasons, and in that case we are the second victims, after patients and their families, who are obviously the first victims.
Indeed, when adverse events occur because of preventable errors, we are the main losers. We tried to achieve a goal, and we failed.
When Pandora opened the jar that Prometheus gave to his brother Epimetheus, every type of misery came out, and humanity experienced illnesses and defeats. Greek myth tells us that Prometheus arrived and closed the jar when hope alone remained inside, at the bottom (3).
Similarly, at the end of Clarkson’s contribution, we perceive an element of hope: the chance to consider every fighter involved in the battle in defence of health as potentially affected by medical error.
Everyone is affected, everyone a victim.
Allies in the therapeutic planning, allies in the defeat.
This scenario could and should be the ground for the emergence of a no-blame culture in both healthcare systems and patient-safety organizations. Once again, patients and physicians can be allies in learning from harmful events how to act differently and do their best for a shared success.
References
1) George, B and Culture Club. (1983). “Victims”. On Colour by Numbers, Virgin Records.
2) Clarkson, MD et al. (2019). Abandon the term “second victim”. BMJ, 364:l1233.
3) Hesiod. Pandora and the Jar in “Works and Days” in Hesiod, Homeric Hymns, Epic Cycle, Homerica. Translated by Evelyn-White. H. G. Loeb Classical Library, Volume 57. London: William Heinemann, 1914.
Competing interests: No competing interests
This article is right on point. As a mother who lost a daughter to medical error, I find the term “second victim” to be inaccurate, deflective and unproductive.
As the patient who is harmed is not commonly called a victim (either in person or in published articles), it is inappropriate to describe providers involved in harm incidents as victims. Even when the patient is seen as the primary victim, what ranking falls to family and loved ones? Our daughter lost her life. Such harm stands alone. Yet Dr. Wu would group loved ones with the patient, or ignore them entirely, to make room to identify the healthcare professional as the second victim. Such ranking is inaccurate, polarizing and serves to deflect responsibility and accountability rather than advancing patient safety.
We must reject the term second victim and focus instead on improving reporting systems, harm reduction measures as well as support for all affected by medical harm.
Competing interests: No competing interests
There is no question that medical errors are much like bombs that damage or destroy everyone involved, in my case even the life of a young attorney that I hired. The most important question is how can our system respond to these tragedies in a way that allows all of the harmed souls to learn and heal. I believe that the ideal response should be:
1. Prompt, Detailed, and h\Honest Disclosure of exactly what went wrong.
2. Sincere apologies by all of the caregivers
3. Elimination of all financial impacts to the harmed.
4. The involved caregiver(s) become champions for change and learning
5. Forgiveness and Restoration
Calling providers victims does not further any of these five goals. Blaming a nebulous system that is designed and controlled by Doctors amplifies the harm.
Healing for all comes through Truth and Action.
Each of these authors have become champions dedicating the remainder of their time on earth to eliminating harm. It is truly tragic that it takes the tremendous losses that they experienced to generate this kind of passion for change. We should listen carefully to what they say.
Competing interests: No competing interests
There is no doubt that health care professionals may be profoundly affected by the medical harm they have caused a patient or their family, but they are not victims. While it is both advisable and appropriate that health care institutions ensure that supportive services be in place for their health care professionals, the only true victims are the patients who have been harmed.
Family members who are also in need of support, are traumatized yet again when they try to inquire about the death or serious harm to their loved ones from the health care institutions where they received care. However, hospitals whose employees have harmed their loved one, even though the harm was unintentional, continue to add insult to injury when they lie or attempt to cover up medical errors in an effort to avoid accountability. This is further compounded by the congenial relationship between hospitals and their regulatory agencies. There is no excuse for victimizing a patient or their family a “second” time by adding additional pain and suffering to their injury.
Competing interests: No competing interests
I worked many shifts as an RN and went home to collapse. I worked without enough help, no support from administration, broken or dirty equipment, and so on. I never ever considered myself a victim. The only victim in healthcare harm is the patient. The workers, nurses doctors and others have a choice and they know if conditions are ripe for harm or neglect. They can continue to work there and fight for positive change, like improved staffing levels and training, better environmental cleaning, more modern and functional equipment, etc They can also call out the harm they see. Or, the workers /caregivers can give up and leave, but they are never a victim. . Patients almost never see harm coming. Because they don't see it coming, they cannot avoid it or call it out. Patients are the ONLY victims in these situations.
I am a retiree member of the National Nurses United. This is the largest nurses union in the US. Nurses who are members can call out understaffing by making out an ADO, which is an assignment despite objection. This is done when the nurse is assigned too many patients or more patients than she/he can handle because of acuity levels. NNU also fights all over this country for mandated safe staffing levels in all settings. Who else is doing that? Are doctors who work 72 hours in a row doing that? Are nurses who are not represented by anyone doing that? If professional caregivers do not call out known unsafe situations for the patients they care for, they cannot cry "I am a Victim". I was never a victim, because I fought for safe staffing. and safe equipment. I also reported UNSAFE nurses and doctors or intoxicated or otherwise impared providers..
We are all adults here. If a caregiver does not have the courage to stand up for safe care, then they should not be whining or calling themselves victims.
Competing interests: No competing interests
From “second victims” to “resilient warriors”: A better framework for supporting healthcare workers involved in medical errors
Dear Editor:
Though published in 2019, this article has renewed relevance in light of the global COVID-19 pandemic that has since ravaged the medical system, driving up the already high rates of adverse patient events due to errors (Rahmani et al., 2020).
Although the authors offered a compelling critique of the "second victim" framework from a patient safety perspective, some have argued that the framework is worth retaining given its potential to reduce the pervasive and persistent mental health effects of adverse patient events for healthcare providers (Busch et al., 2021). These mental health effects, in turn, increase the likelihood of further adverse events due to medical errors (e.g., West et al., 2006) thus perpetuating a negative spiral of worsening provider wellbeing and patient care that will likely continue to haunt the medical system long after the pandemic ends (e.g., Lancee et al., 2008).
But is the “second victim” framework actually suited to address these mental health effects?
When Wu (2000) originally coined the term "second victim," he used it specifically in reference to physicians who had been unjustly vilified by a punitive, unsympathetic medical system in which there was "no place for mistakes.” To correct for this systemic denial of fallibility, with its resultant intolerance toward and scapegoating of errant physicians, Wu called upon the medical system to de-stigmatize errors as a normal and near-ubiquitous experience among providers--one that warrants sympathy and support, not condemnation and dismissal.
Interestingly, however, modern definitions of "second victim" make no mention of errors, instead applying the label broadly to any provider who has been "harmed by an adverse event” (Busch et al., 2021). Accordingly, second victim support programs focus on instilling a “no-blame mentality” and reducing emotional distress (e.g., Dukhanin et al., 2018; Scott et al., 2009). As the authors note, these programs do not typically distinguish between adverse events due to errors versus other causes, much less between errors due to inadequate staffing, lack of knowledge, or extreme fatigue, for example.
Yet disentangling these complex, often interactive causes so that one can understand, forgive, and, where possible, remediate one’s errors is among the crucial steps to psychological healing—and perhaps the hardest to achieve without support.
Indeed, in their uniform focus on removing blame, these support programs may inadvertently be reinforcing the very message that Wu’s “second victim” concept was meant to counteract: that owning up to one’s errors is disastrous and impermissible.
To achieve its intent of providing a safe, supportive environment for coping with errors, the medical system needs to normalize and de-stigmatize the acknowledgement of errors, rather than remove awareness or accountability for them. Such an approach would involve promoting and publicly modeling the honesty and courage required to own one’s medical errors, and to learn and grow in light of them.
Indeed, psychologists have learned that “victim” labels rarely promote healing among traumatized individuals. On the contrary, they tend to increase feelings of shame and helplessness (Papendick & Bohner, 2017). A converging insight of trauma and resilience research is that posttraumatic recovery hinges on restoring one’s sense of agency and control over one’s life (Gorlin & Bekes, 2021)—including the recognition of whatever choices one had available in the context of the trauma, and the identification of whatever corrective actions one can take going forward.
Likewise, “reducing emotional distress” is not always the right target to aim at when supporting errant providers. Contrary to the harsh, self-condemnatory self-talk that often accompanies a costly error, feelings of guilt and remorse after an error are not signs of weakness or defectiveness, but of moral health: they signal how strongly the provider values her work and the patients she serves. Indeed, the numbing of painful emotions may signify a more troublesome reaction to trauma, leading to greater burnout and lower investment in patient care (e.g., Austin, 2016; Kashdan et al., 2016).
Perhaps most crucially, the “second victim” label fails to do justice to the courage and fortitude of healthcare providers, whose occasional errors occur in a context where many more lives would be claimed if not for their efforts. Interestingly, a September 2020 study found that physicians directly involved in treating COVID-19 reported less burnout than those who were not (Dinibutun, 2020). While it is important not to understate the pandemic’s intense emotional and physical toll on healthcare providers, this does not preclude the possibility that they may also derive a sense of meaning and purpose from their service on the frontlines. This sense of purpose is a vital resource to leverage when supporting providers through the errors and losses that are an inescapable reality of their chosen work.
The psychological experience of COVID-19’s frontline medical providers has been widely analogized to that of traumatized soldiers (e.g., Williams, 2020). Drawing on this analogy, we recommend that the medical system shift from a “second victim” to a “frontline warrior” framework for supporting providers who err. A hard-won lesson of psychologists’ work with military personnel who feel responsible for the loss of human life is that they are not looking to be relieved of this responsibility (e.g., Litz et al., 2009, 2017; Norman et al., 2014). On the contrary, they are looking for someone to respect them enough to take it seriously. Taking it seriously does not mean accepting the provider’s initial guilt-ridden narrative at face value; rather, it means identifying and honoring the core values that have led them to assume such responsibility in the first place, and supporting their need to hold themselves accountable by grappling with the full complexity of what happened and how their choices may have contributed. This may mean surfing intense waves of anger, sadness, and remorse together with the provider as they acknowledge, grieve, and take action to remedy their errors, thus redoubling their commitment to the values that give their work meaning.
Let us respect our frontline medical warriors enough to stop calling them “victims”—and to honor their ownership of the errors and losses inherent in the fight for human life.
References
Austen L. Increasing emotional support for healthcare workers can rebalance clinical detachment and empathy. British Journal of General Practice. 2016;66(648), 376-377.
Busch IM, Moretti F, Campagna I, Benoni R, Tardivo S, Wu AW, Rimondini M. Promoting the Psychological Well-Being of Healthcare Providers Facing the Burden of Adverse Events: A Systematic Review of Second Victim Support Resources. International Journal of Environmental Research and Public Health. 2021;18(10):5080.
Dinibutun SR. Factors Associated with Burnout Among Physicians: An Evaluation During a Period of COVID-19 Pandemic. J Healthc Leadersh. 2020;12:85-94.
Dukhanin V, Edrees HH, Connors CA, Kang E, Norvell M, Wu AW. Case: A Second Victim Support Program in Pediatrics: Successes and Challenges to Implementation. J Pediatr Nurs. 2018;41:54-59.
Gorlin EI, Vera B. Agency via awareness: A unifying meta-process in psychotherapy. Frontiers in Psychology. 2021;12:2587.
Kashdan TB, Elhai, JD, & Frueh BC. Anhedonia and emotional numbing in combat veterans with PTSD. Behaviour Research and Therapy. 2016;44(3), 457-467.
Litz BT, Lebowitz L, Gray MJ, Nash WP. Adaptive disclosure: A new treatment for military trauma, loss, and moral injury. Guilford Publications; 2017
Litz BT, Stein N, Delaney E, et al. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009;29(8):695-706.
Norman SB, Wilkins KC, Myers US, & Allard CB. Trauma informed guilt reduction therapy with combat Veterans. Cognitive and Behavioral Practice. 2014;21(1):77-88.
Papendick M, Bohner G. "Passive victim – strong survivor"? Perceived meaning of labels applied to women who were raped. PLOS ONE. 2017;12(5): e0177550.
Rahmani S, Deldar K, Hemati Ali, S. Medical errors during COVID-19 pandemic: the role of emergency medicine. Journal of Emergency Practice and Trauma. 2020.
Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330.
West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078. doi:10.1001/jama.296.9.1071
Williams R.D, Brundage JA & Williams, E.B. Moral Injury in Times of COVID-19. J Health Serv Psychol. 2020;46:65–69.
Wu AW. Medical error: the second victim. West J Med. 2000;172(6):358-359.
Competing interests: No competing interests